Currently, the healthcare industry represents 15% of the country's GNP. Americans spend considerably more than citizens of any other developed country on healthcare and yet Americans' life expectancy and infant mortality rates rank toward the bottom of these countries. A growing number of Americans are losing their health insurance because it is becoming increasingly unaffordable. Current estimates place the number of uninsured at 45,000,000 to 47,000,000. The supply of physicians is becoming an increasingly critical problem. The United States ranks 43rd in the world in the number of physicians per capita just as the “baby-boomer” generation begins to reach retirement age. Most experts have declared the current healthcare delivery system as unsustainable. The present invention is directed to a method and web-based system for improving the delivery of healthcare related services by increasing communication between the service providers and patients, increasing the amount of knowledge a patient has about his or her health condition, providing a system of “checks and balances” to measure and motivate patient and service provider adherence to an accepted performance standard, and providing performance-based rewards to the service provider and patient for their participation in the system.
Since the mid-1980s, several attempts have been made to control healthcare costs. The attempted reforms only temporarily slowed the escalation of healthcare costs during the mid to late 1990s. Recently healthcare costs have risen at an alarming rate—three to four times the rate of inflation during the time period from 2001 through 2006. Control of healthcare costs can be accomplished by elevating the efficiency and effectiveness of the standard of care and by improving the country's overall level of healthiness.
Various studies have concluded that healthcare costs are increasing for the following reasons:                High Cost Coupled with Poor Healthcare Quality Equates to Low Value—Healthcare in the United States is more expensive than any other developed country and life expectancy and infant mortality in the United States ranks toward the bottom of developed countries. A study by the RAND Corporation determined that Americans receive recommended care only 55% of the time. (See McGlynn E A. The Quality of Healthcare Delivered to Adults in the United States. RAND Corporation.) This low level of healthcare causes inferior clinical outcomes and higher costs.        Variability of Care—Another cause of poor quality of care is the variability of care from provider to provider and from geographic location to location. (See Wennberg J., Small Variations in Healthcare Delivery, and Understanding Geographic Variations in Healthcare Delivery and Dartmouth Atlas of Healthcare 1998.) Variability in healthcare indicates a degree of over-treatment, under-treatment and mistreatment that contributes to inferior clinical outcomes and higher cost.        Hospital Medical Errors—The fourth leading cause of preventable death is due to errors committed in hospitals, accounting for as many a 195,000 deaths per year. (See HealthGrades, Patient Safety in American Hospitals, 2004.) This is a tragic situation in terms of human loss. Beyond the human toll, the economic impact of hospital errors on victims and survivors is enormous.        A Large and Growing Population of Uninsured—47 million Americans are without health insurance coverage, and this number continues to grow as coverage becomes increasingly unaffordable.        Poor Doctor-Patient Communications—Studies have documented that a leading complaint about healthcare among patients is the poor communications with their doctors. Doctors interrupt patients within the first twenty-three (23) seconds of an encounter. (See Beckman H B. The Effect of Physician Behavior on the Collection of Data.) Fifteen percent (15%) of patients fully understand what their doctors tell them and fifty percent (50%) leave their doctors' offices uncertain of how to care for themselves. (See Kaplan S H, Is Your Doctor Really Listening to You?, University of California, Irving, National Center for Policy Analysis. Daily Policy Digest; 2004 citing Levine M. Tell the Doctor All Your Problems, but Keep It to Less Than a Minute.) Poor doctor-patient communications causes misdiagnosis, inferior clinical outcomes, malpractice, and higher costs. (See Stewart M A., Effective Physician-Patient Communication and Health Outcomes: A Review; and Levinson W., Physician-patient Communication. The Relationship with Malpractice Claims among Primary Care Physicians and Surgeons.)        Lack of Patient Medical Knowledge—Most patients do not understand their medical condition well enough to effectively self-manage their health. As a result, patients either become too dependent on their doctors for managing their health or they do not seek healthcare until it is too late. In either case, the cost of healthcare is negatively impacted.        Misaligned Provider and Patient Incentives—There are six incentive misalignments that are characteristic of the American healthcare delivery system that drive costs higher. First, the primary method for compensating providers, especially physicians, is based on the volume of services rendered as opposed to the quality or value of services rendered. This volume-based method of reimbursement encourages physicians and hospitals to provide more care as opposed to better care. Second, American medical providers are primarily compensated to treat illness and injury. They are compensated very little to prevent disease and injury, and are not compensated at all to cure patients or for elevating healthiness. Third, American healthcare is one of the only industries or professions where providers routinely get paid to fix their mistakes. Fourth, providers practice what is referred to as “defensive medicine” to avoid medical malpractice lawsuits. In so doing, doctors perform procedures and order tests that may provide lawsuit protection but have been determined by evidence-based medicine to be unnecessary for the health of the patient. Research has concluded that defensive medicine increases healthcare cost by 5% to 9%. (See Kessler D., Do Doctors Practice Defense Medicine?) The fifth misalignment involves how most health insurance plans induce patients to behave. When patients have little or no out-of-pocket costs, a degree of entitlement occurs. Furthermore, health benefits do not reward patients for healthy behaviors or compliance to care recommendations. The sixth misaligned incentive is how pharmaceutical companies market to consumers and pander to physicians to sell brand name drugs when generic or substitute drugs are just as effective. All six of these incentive misalignments stimulate healthcare inflation because these misalignments discourage patients and healthcare service provider accountability and do not empower the parties to improve health or control costs.        A Disparity between Who Controls Healthcare Costs and who is compensated for Delivering Healthcare Affects Healthcare Inflation—Medical practitioners (physicians) and patients (consumers) control the vast majority of cost (approximately 80%). In effect, physicians are the only party licensed to admit and discharge people in and out of a hospital, and are, effectively, the only party licensed to write drug prescriptions and other types of therapies and diagnostic services. Patients are the only party that can choose to follow recommended treatments and adopt healthy lifestyles—a factor that drives the vast majority of healthcare consumption. The epidemic state of obesity and diabetes are recent phenomenon directly related to such lifestyle choices. Therefore, physicians and patients control the vast majority of healthcare consumption, and yet physicians receive less of the premium dollar (19%) than pharmacy (22%), administration and underwriting (250%) and hospitals (28%).        Unhealthy Behaviors—Americans are increasingly unhealthy with preventable diseases such as obesity and diabetes reaching near epidemic rates. This is a primary cause of healthcare inflation.        American Healthcare Delivery is Inefficient—According to a Boston University study, inefficiencies in the American healthcare delivery system may account for 50% of the total cost of healthcare.        Slow Adoption of Medical Advancements—The delay in full adoption, seventeen years in some cases, of advancements in medicine by the medical profession is a contributor to inferior health care that can lead to higher total and long term costs.        
Additional studies and the consensus of opinion have concluded the following:                When the standard or quality of healthcare improves then clinical outcomes improve and overall costs are reduced. Thus, the efficacy of a healthcare quality improvement program can be measured by cost trends.        Evidence-based medicine (EBM) treatments represent the highest standard of care. The term EBM, as used herein, means “ . . . the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D L, Rosenberg W M C, Gray J A M, Haynes R B, Richardson W S., Evidence Based Medicine: What It Is and What It Isn't. BMJ 1996; 312: 71-2.) The consensus of expert opinion holds that EBM must be an integral part of any serious solution to improving the health care delivery system.        Americans would prefer that their healthcare providers be compensated on the basis of value as opposed to volume. (Blue Cross and Blue Shield Association of America.)        Incentive-based (“pay-for-performance” or “P4P”) programs have demonstrated that providers can be motivated to report quality measurements. These programs have also demonstrated improvements in the standard of care and clinical outcomes. However, no P4P program has been able to demonstrate sustainable cost containment that produces a return on investment (ROI) for the purchaser, to date. (“Efficiency” is another term used to describe a P4P program that is able achieve simultaneous health care quality improvement and cost containment.)        Physicians find incentive-based programs that mandate adherence to guidelines treatment protocols as objectionable. Many medical practitioners consider these types of P4P programs as “cookbook medicine”, counterproductive, potentially dangerous, and will be rejected by the medical community. (American Medical Association)        Information therapy (Ix) changes patient behavior, improves clinical outcomes, and lowers costs. (Blue Cross and Blue Shield Association of America and RAND Corp) As used herein, Ix is defined as dispensing the right clinical information, at the right time, so the patient can make the right decision about the management of their health. Proponents of Ix agree that it is powerful medicine. (Center of Information Therapy). Another way of describing Ix and its importance is to recognize and acknowledge that an uninformed or misinformed patient will have worse clinical outcomes and consume more healthcare resources than a patient that is medically literate. Information therapy provides a means for reducing medical illiteracy.        Electronic health records (EHRs) and personal health records (PHRs) will allow the sharing of patient medical records between service providers. Sharing of patient medical records improves the efficiency and effectiveness of healthcare delivery and adds to patient safety. However, service providers and consumers/patients have been slow to adopt EHRs and PHRs because the value proposition for adoption has been inadequate, to date. In other words, the financial and other incentives have not been sufficient for the vast majority of medical practitioners and consumers to invest the time and money to adopt EHRs and PHRs.        Electronic order entry allows the service provider to prescribe drugs and refer patients to a specialist or other healthcare providers more efficiently and effectively. Electronic order entry of pharmacy prevents errors due to a doctor's illegible hand writing and due to multiple parties handling drug a single prescription. It also provides a means through the Internet to: 1) automate the use of drug formularies that suggest equally effective yet less expensive alternative drugs including generic drugs to doctors, pharmacists and patients; 2) warn doctors and patient of possible harmful drug interactions; and provide the doctor and patient with pharmacy educational information. (This type of electronic order entry can also be referred to as drug therapy management.) Electronic order entry of patient referrals eliminates the time and expense involved in doctor offices or patients calling other doctor offices to for appointments. It also provides a means to forward patient medical information electronically which can significantly improve the efficiency of care and prevent errors and miscommunications. Electronic referrals also helps ensure that the patient makes and keeps an appointment with a specialist.        Pre-authorization certification (pre-cert programs) of expensive medical services (such as surgeries, hospitalizations, and radiological tests like MRIs) has been a long stand practice in health care. In effect, medical providers are required by health plans (healthcare purchasers/payers/funders) to have expensive medical service approved by a third party medical expert to prevent unnecessary services. Typically, patients are not expected or required to be part of the decision-making process.        
Comprehensive hospital care management is designed to help insure patients receive the safest and most effective care during a hospitalization. The Institute of Medicine (IOM) offers a list of suggestions for patient safety during hospitalization such as insisting caregiver wash their hands to prevent infection, changing bed linens and turning patients to prevent bed sores and having patients designate advocates (family and friends) to watch over them during hospitalizations. Typically, patients and their advocates are not expected or required to be part of the hospital care management.
According to experts, the success of incentive-based (P4P) programs will hinge on:                Service provider and patient acceptance, participation and compliance with performance standards that improve the standard of care and level of healthiness that lead to better clinical outcomes and lower overall costs;        Incorporation of performance standards that have been effective such as EBM, Ix, EHRs, PHRs, electronic order entry, drug therapy management, and hospital care plans;        Investment in quality improvements to achieve cost control;        Effective control of fraud and abuse;        The cost and complexity of deploying and maintaining incentive-based programs; and        The return on investment to the healthcare purchaser/payer.All of these factors contribute to the quality and cost of healthcare and will determine the success of P4P programs.        
The current invention is directed to improving the delivery of healthcare and the maintenance of good health by creating a system of incentives that align the interests of healthcare's essential stakeholders—healthcare service providers (principally physicians and hospitals), consumer/patients, and purchasers/payers (health insurers, self-insured employers, and the government's Medicare and Medicaid programs). Other quality improvement and cost containment methods consistently fail to recognize or accommodate for this fundamental success criterion of stakeholder alignment. Therefore, the challenge to reforming healthcare has been creating a solution that offered a simultaneous win-win-win proposition among these key stakeholders. The present invention provides an effective system to lower healthcare costs by “triangulating” the interests of the provider, the patient and the purchaser to improve the standard of care and encourage healthy behaviors that leads to better health.